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The actual ranges for cycle length, bleeding and pain, what causes heavy periods, every treatment in the order guidance recommends, and the iron problem that gets missed.
Reviewed by Dr. Grishma Ranjangaonkar, MBBS, DGO, ICOG Fellowship in Gynecological Endoscopy · Eva WomanCare Clinic, Vashi
Most women measure their cycle against a 28-day textbook version that almost nobody has, and put up with bleeding or pain for years because nobody told them where the line is. This guide sets out the real ranges, what causes heavy or painful periods, and what can be done about each, in the order the evidence supports.
Most women have never been told the ranges, and so measure their own cycle against the 28-day textbook version that almost nobody actually has. Here is what the ranges really are.
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Normal range
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Worth investigating
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In a large proportion of women no structural cause is found, and that is a real finding rather than a failure to look properly. Where there is a cause, these are the usual ones.
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Cause
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The clue
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What is usually done
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Treatment is not a single ladder. What suits you depends on whether you want a pregnancy soon, whether there are fibroids and how large, and how much you want to avoid hormones.
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Treatment
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How it works
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Who it suits
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Cramping on the first day or two, responding to a simple painkiller taken early, is ordinary. Pain that dictates your month is not, and the average delay between a woman first reporting it and a diagnosis of endometriosis is measured in years rather than months.
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Pattern
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What it suggests
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What to do
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Heavy is one problem. Unpredictable is a different one, and it is investigated differently.
Heavy periods cause iron deficiency, iron deficiency causes exhaustion and breathlessness, and the two are very often treated as separate problems by different people. A full blood count is recommended for every woman with heavy menstrual bleeding, alongside whatever treatment is started, not instead of it.
Myth
“A 28-day cycle is what normal means.”
What is actually true
Anything from 24 to 38 days is normal, and most women are not on 28. What matters more than the number is whether it is consistent for you, and whether it has changed.
Myth
“Heavy periods just run in the family.”
What is actually true
Sometimes there is a genuine familial cause, and it is a bleeding disorder rather than bad luck. Heavy periods since they first started, particularly with easy bruising or bleeding after dental work, is exactly the pattern that should prompt testing for a coagulation disorder.
Myth
“Period pain is normal and you have to put up with it.”
What is actually true
Cramping on the first day is ordinary. Pain that dictates your month is not. This belief is the main reason endometriosis takes years to diagnose, and it is worth rejecting firmly.
Myth
“You should not have a scan or an examination unless the bleeding is extreme.”
What is actually true
Assessment is based on the effect on your life, not on a volume. Guidance says explicitly that treatment should aim to improve quality of life rather than to reduce a measured blood loss.
Myth
“Having a baby will fix it.”
What is actually true
Sometimes periods do change after a pregnancy, in either direction. It is not a treatment, it is not predictable, and it is not a reason to postpone finding out what is going on.
Most menstrual problems are treatable, and most women wait far too long. Any of these is a reason to make an appointment rather than to keep managing it.
Assessment, investigation and treatment of heavy menstrual bleeding follow NICE guideline NG88, including the recommendation of the levonorgestrel-releasing intrauterine system as first-line treatment and the advice against routine female hormone testing, routine thyroid testing and blind endometrial biopsy. Recommendations on endometriosis follow NICE guideline NG73. This guide is general information and does not replace advice from your own doctor, who has your history and your results.
If your cycles are irregular or infrequent rather than heavy, start here.
The commonest reason for unpredictable cycles, and what is actually assessed.
For when investigation or treatment moves to surgery, including for endometriosis.
Because the treatment that helps heavy periods most is also a contraceptive.
The assessment is a history, an examination, a blood count and usually a scan. Most women who come in having managed heavy or painful periods for years leave with a plan at the first visit, and the commonest reaction afterwards is that they wish they had come sooner.
